Incident reporting barriers

Firth-Cozens, J. (2002) Barriers to incident reporting. Quality and Safety in Health Care, 11 (1),7. 

Evans, S. M., et al.. Attitudes and Barriers to Incident Reporting A Collaborative Hospital Study, Quality Safety in Health Care, Vol. 15, 2006, pp. 39-43. 

Lawton, R., and Parker, D. Barriers to Incident Reporting in Healthcare Systems. Quality and Scfety in Health Care. 2002, 15-18. 

General The incident report provides an overall criticism of Statoils structure and systems. Specifically it appears that the barriers that were in piace to ensure safety were either misunderstood or ignored. 

Near miss incident reporting is not encouraged by the organization. Language barriers. 

Lawton R, Parker D (2002) Barriers to incident reporting in a heedthcare system. Qual Stif Health Care 11 15-18... 

As anticipated, there have been occasional equipment failures involving reactors, but the safety systems have been sufficiently redundant so that one or more have always worked. Even in the Three Mile Island accident in 1979, the safety systems worked as designed. Much of the damage resulted from operator actions to override the safety systems. As concluded in the Reactor Safety Report, the limitations of the operator created and then seriously aggravated the Three Mile Island incident. Nevertheless, the features of the containment system prevented significant exposure to the plant personnel or any off-site individual, this despite failure of the barriers provided by the fuel cladding and the primary coolant system. 

In low dosages scopolamine can produce effects on the CNS, presmnably due to its ability to penetrate the blood-brain barrier. Drowsiness and confusion are frequently reported. Patients also tend to exhibit a higher incidence of idiosyncratic reactions to scopolamine than to other anticholinergic agents, and, hence, it is not the drug of first choice for cycloplegic refraction or treatment of anterior uveal inflammations. Its use is reserved primarily fiar patients who exhibit sensitivity to atropine. 

Related to bias, the accident reports were mainly focused on past incidents with negative outcome, area-1 from Figure 1. There was little focus on opportunities to improve resilience or discuss reliability/ resilience as observed. The emergency preparedness was discussed in 10 of the 28 reports, documenting approximately on V4 the barriers functioning... 

There was no explicit assessment of safety culture, in combination with a quantitative evaluation of the HSE environment in the accident reports. Such an assessment could be used to get a collective measure or temperarnre of the priority of safety in the organization, related to best practice . In Itho (2004) there is shown a correlation between the level of safety culture and quantitative incidents/acddents thus safety culture could be used as an indicator of the holes in harriers or the level of erosion of barriers, in combination with quantitative HSE data. A more specific measure tan culture is described by Rundmo (1997) i.e. when an employee in the Norwegian oil and gas industry feels at risk he/she is at risk. A proactive indicator could thus be a workplace survey, measuring risk perceptions or performing a more broadly based assessment of safety culture in combination with other local quantitative indicators such as gas emissions, injuries compared with best practice in the industry. 

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